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Worried nurses react differently to attacks on staff and patients in psychiatric wards

13.04.2007

Psychiatric nurses have a one in ten chance of being physically injured by an aggressive patient over the course of a year and many more suffer emotional distress because of the verbal abuse they receive while working in these difficult and challenging environments.

But the fear experienced by staff may be greater than the actual risk and frequently results in aggressive patients being put in seclusion or restrained, especially when the victim is a staff member, according to research in the latest Journal of Advanced Nursing.

Researchers from The City University, London, recorded 254 aggressive incidents on five acute inpatient psychiatric wards over a ten-month period.

They discovered that although the most common approach used by staff after an incident was to talk to the patient – this happened in 44 per cent of cases - they were much more likely to put a patient into seclusion or restrain them if the attack was against a staff member rather than another patient.

57 per cent of the aggressive incidents that took place at the inner city hospital were aimed at staff, 19 per cent involved other patients and 12 per cent resulted in self harm.

Seclusion was used to resolve more than a quarter of all incidents, with a further 23 per cent resulting in the patient being held by force.

“Our data suggest that the majority of aggressive incidents on the ward were directed at staff members, but that the smaller number of incidents against other patients resulted in greater physical harm” says lead researcher Chloe Foster, who is now based at the Institute of Psychiatry in London.

“Staff were much more likely to talk to the perpetrator when the victim was another patient and seclusion was used in 25 per cent of cases.

“However, when the victim of the aggression was a member of staff, the seclusion rate increased to 36 per cent.”

Physical abuse accounted for a sixth of the 145 incidents involving staff, with verbal abuse accounting for the remainder. Staff were commonly hit or pushed by the patient’s hand, with one being attacked with hot water. In eight per cent of incidents staff were hurt or required treatment.

78 per cent of the nursing staff who took part in the study said they felt threatened by the abuse they received and they recorded an average severity score of just over 12 on a scale of zero to 22.

The team also recorded 48 aggressive incidents against other patients, with physical aggression being used in just under half of cases (46 per cent). A quarter of the incidents resulted in other patients being injured or needing treatment, with three attacks featuring a knife, hot tea or a teapot.

70 per cent of the patients who were subjected to aggressive behaviour said they felt threatened by the incident.

The researchers point out that the number of incidents that took place during the study period was probably higher than recorded for several reasons.

“Only severe verbal aggression was recorded and staff may not have had enough time to record incidents that happened during shift changes or when they were about to go off duty” explains Foster. “It is also possible that a number of incidents between patients weren’t noticed by staff. So these incidents should be seen as minimum figures.”

The research team also looked at what triggered the aggressive outbursts. They found that the most common cause was a patient being denied something - for example being refused permission to leave the ward accounted for just under a third of incidents.

“Violence prevention training courses in the UK are aimed at avoiding eruptions of patient aggression, minimising the risk of injury, reducing the need for harsh coercive measures and helping patients control their behaviour” concludes Foster.

“Our findings suggest that training also needs to focus on improving methods of communication between staff and patients. This would enable staff to identify the factors that provoke patient aggression, recognise the importance of interpersonal factors in provoking such incidents and reduce aggression on psychiatric wards.”

The researchers are keen to point out that, although their research suggests that nurses may have taken firmer action than needed on a number of occasions, the fear experienced by staff working in mental health areas is very real and highly understandable.

“Numerous surveys in the UK have shown how vulnerable healthcare staff are, that nurses experience the highest number of aggressive incidents and that incidents are two and a half times more likely in mental health and learning disability services” stresses Foster.

“We hope that our research will help to create a better understanding of why aggressive incidents occur and enable health service providers to give their staff the extra training and support they need to work in these challenging environments.”

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